Wiki Physical Exam Coding Question

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LindsayC

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I am in the process of learning the basics of E&M. I have an example that I was determining level of service for.

Part of the physical exam stated:

Cardiovascular - Normal.

The example said that this could count as Cardiovascular on the 95 Guidelines. I feel like this is incorrect because no detail was given on what was normal.

Can anyone help clear that up either way?

Thanks!
 
Well, technically it could count because of the statement in the 1995 DGs that says "A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to the unaffected area(s) or asymptomatic organ system(s)." Hence one of the annoying grey areas in E/M coding, especially in 1995 guidelines.
That said, local and commercial carriers sometimes have their own criteria for what they'll accept. I would definitely speak to the physician regarding his/her poor documentation practices, however, because this may or may not be defensible in an audit setting.
 
The 95 Documentation Guidelines do clearly state that a notation of "negative" or "normal" is acceptable. You can't say something is abnormal without elaborating however.

For further verification, here's a quote from my local Medicare carrier, NHIC, on the issue. Feel free to check with yours.

Question 6. When using the 1995 guidelines for the physical exam, can I say “unremarkable” if
an organ system has normal findings?
Answer 6. Unremarkable is acceptable related to unaffected area(s) or asymptomatic organ
system(s).
Click to expand...
 
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